BACKGROUND: Cluster headache (CH) is a rare but severe primary headache disorder characterized by recurrent attacks of unilateral, typically periocular pain lasting 15 min to 3 h, accompanied by ipsilateral autonomic sym...BACKGROUND: Cluster headache (CH) is a rare but severe primary headache disorder characterized by recurrent attacks of unilateral, typically periocular pain lasting 15 min to 3 h, accompanied by ipsilateral autonomic symptoms and restlessness or agitation. Attacks may occur multiple times daily and present in clusters lasting weeks to months, interspersed with remission periods in episodic CH, or without remission in chronic CH. METHODS: This review summarizes the clinical evidence supporting the use of transcutaneous cervical vagus nerve stimulation (tcVNS) for both the acute and preventive treatment of CH. Relevant clinical trials, real-world studies, and guideline recommendations are discussed. RESULTS: Pharmacological therapy for CH includes triptans and high-flow oxygen for acute management, and verapamil, corticosteroids, or galcanezumab for prevention. For patients with inadequate response or intolerance to these options, neuromodulation may be required. TcVNS has emerged as a noninvasive, safe, and effective alternative to invasive neuromodulation. Clinical trials have demonstrated significant reductions in attack frequency and intensity, leading to U.S. Food and Drug Administration (FDA) clearance and UK National Institute for Health and Care Excellence (NICE) approval for both acute and preventive treatment of CH. CONCLUSIONS: TcVNS represents a well-tolerated, noninvasive neuromodulatory option for patients with cluster headache, offering both acute and preventive benefits. This paper provides an overview of the current evidence, mechanisms of action, and practical guidelines for incorporating tcVNS into clinical management.
BACKGROUND: Complex Regional Pain Syndrome (CRPS) in the upper limb is a rare and challenging pain condition that usually develops following an injury. No studies have identified influential aspects of healthcare specifi...BACKGROUND: Complex Regional Pain Syndrome (CRPS) in the upper limb is a rare and challenging pain condition that usually develops following an injury. No studies have identified influential aspects of healthcare specific to upper limb CRPS or the New Zealand (NZ) healthcare context. The aim of this study was to explore people's experiences of diagnosis and treatment for upper limb CRPS in NZ. METHODS: An online survey was designed from themes identified in a preceding interview study. Participants were recruited from healthcare services NZ-wide, social media, and through online advertisements. Eligibility criteria were: 18 years or older, diagnosis of upper limb CRPS for more than 3 months and less than 3 years, and reporting high levels of ongoing pain and three or more CRPS symptoms over the past 48 h. Data were exported to SPSS software for descriptive analyses. RESULTS: Seventy-five people participated in the survey (91% female, mean age 50 years, SD 13). Nearly half of participants (43%) identified being diagnosed within 1-3 months of symptom onset. Most (81%) desired more accompanying information. Support and guidance were identified as the most valuable aspects of healthcare (72%). Participants reported difficulty accessing required treatment (60%) at the right time (61%). Nearly all participants (98%) perceived that having easy ongoing access to healthcare was important. CONCLUSIONS: People with upper limb CRPS prioritize early access to information and support to navigate complex systems. Updated online information about region-specific CRPS treatment options needs to be made readily available to both people with CRPS and healthcare professionals.
INTRODUCTION: Spinal cord stimulation (SCS) is a well-established treatment for chronic pain. Thoracic laminotomy is highly effective for placing thoracic epidural leads; however, safely placing paddle leads midline at t...INTRODUCTION: Spinal cord stimulation (SCS) is a well-established treatment for chronic pain. Thoracic laminotomy is highly effective for placing thoracic epidural leads; however, safely placing paddle leads midline at the correct target level can be challenging because of anatomic constraints and the inherent difficulty in counting vertebral body levels in the thoracic spine. OBJECTIVE: The authors outline three basic surgical techniques, focusing on identifying the correct level for placement and creating adequate decompression for safe midline placement. METHODS: We analyzed 289 patients who underwent SCS placement to characterize our surgical technique. We evaluated the operative setup, preoperative planning, and three basic surgical approaches: a "below-level" laminotomy, "same-level" laminotomy, and "second" or two-level laminotomies at and below the lead's placement level. RESULTS: A total of 289 patients (mean age of 64.5 years) underwent thoracic SCS placement. Surgical techniques included below-level laminotomy (55%), same-level laminotomy (21%), and second laminotomy (24%). The majority of SCS paddle leads were placed at T8/9 (65%). The operative time from skin incision to closure for below-level, same-level, and second laminotomy techniques was 66, 74, and 87 min, respectively. Most patients (86%) were discharged on the same day. CONCLUSION: This study highlights the surgical options for accurate midline placement of thoracic SCS paddle leads: below-level laminotomy for most cases, same-level laminotomy for patients with thoracic stenosis, and two-level laminotomy for challenging placements. We advocate for preoperative imaging and individualized surgical methods based on preoperative canal diameter measurements and intraoperative findings to ensure safe placement.
BACKGROUND: This study aimed to conduct a comprehensive bibliometric analysis of the global scientific literature on botulinum toxin from 1991 to 2024, evaluating publication performance, citation impact, and emerging re...BACKGROUND: This study aimed to conduct a comprehensive bibliometric analysis of the global scientific literature on botulinum toxin from 1991 to 2024, evaluating publication performance, citation impact, and emerging research foci. METHODS: Data were retrieved from the Science Citation Index Expanded (SCI-EXPANDED) of the Web of Science Core Collection. The data extraction procedure included titles, abstracts, author keywords, and Keywords Plus. Publication and citation metrics (TP, IP, CP, FP, RP, SP, CPP) were analyzed across countries, institutions, authors, and journals. Trends in document types, language, categories, and keywords were also examined. RESULTS: A total of 25,522 relevant documents were identified, with a marked increase in publications over time. The United States led in publication output and citation impact, followed by Germany, the United Kingdom, and China. Notably, countries such as South Korea, Italy, France, and Turkey showed a recent surge in output. Allergan Pharmaceutical Inc. demonstrated the highest citation performance among all institutions. Three primary research themes were identified: clinical indications, administration and formulations, and evaluation of efficacy and safety. The findings also highlighted increased international and interdisciplinary collaborations over time, as well as growing interest in surgical and aesthetic applications. CONCLUSION: Botulinum toxin research has grown significantly in both scope and volume over the past three decades, with notable contributions from both academic and industrial institutions. Understanding global research performance and thematic trends provides a foundation for future clinical, academic, and commercial development in the field.
INTRODUCTION: Dorsal root ganglion stimulation (DRGS) is a recognized treatment for chronic neuropathic pain. A well-known complication is electrode migration, which most commonly occurs in a caudal direction. OBJECTIVE:...INTRODUCTION: Dorsal root ganglion stimulation (DRGS) is a recognized treatment for chronic neuropathic pain. A well-known complication is electrode migration, which most commonly occurs in a caudal direction. OBJECTIVE: To present a rare clinical case of cranial migration of a DRGS electrode into the mediastinum. CASE PRESENTATION: A 62-year-old woman with pharmacoresistant intercostal neuralgia underwent DRGS electrode implantation at the Th2 level using a standard linear lead, as specialized DRGS electrodes were unavailable. Initial therapy was effective. However, follow-up imaging approximately two years post implantation revealed that the electrode had migrated cranially through the Th2-Th3 intervertebral foramen. The tip was located in the mediastinum, in immediate proximity to the right subclavian artery, creating a significant risk of vascular or pleural injury. The electrode was successfully and safely explanted. CONCLUSION: This is the first reported case of mediastinal migration of a DRGS electrode. It highlights the unique risks associated with off-label cranial DRGS applications due to anatomical constraints and gravitational forces. The case underscores the urgent need for the development and use of specialized electrodes designed for such locations and reinforces the importance of improved fixation techniques and long-term postoperative vigilance to mitigate migration risks.
OBJECTIVE: Traditional therapies for postherpetic neuralgia (PHN) and postherpetic itch (PHI) often yield unsatisfactory outcomes. Previous investigations on extracorporeal shockwave therapy (ESWT) have demonstrated posi...OBJECTIVE: Traditional therapies for postherpetic neuralgia (PHN) and postherpetic itch (PHI) often yield unsatisfactory outcomes. Previous investigations on extracorporeal shockwave therapy (ESWT) have demonstrated positive outcomes in pain and itch reduction in conditions resembling PHI and PHN, exhibiting neuropathic mechanisms. This study aims to evaluate the impact of ESWT on pain and itch associated with PHN and PHI. METHOD: Inclusion criteria encompassed individuals aged 50 to 80 displaying symptoms indicative of PHN or PHP (persistent pain duration exceeding 3 months), undergoing conventional conservative therapies like combination medication and nerve blocks, with reported pain or pruritus scores surpassing 3 on a numerical rating scale (NRS) (treatment group, n = 10; sham stimulation group, n = 9). The experimental group received 2000 shock waves per treatment, with each shock wave comprising 100 impulses/cm, characterized by low-energy flux density (0.07-0.20 mJ/mm), administered with a 1-week interval between treatments over 6 weeks. RESULT: After two sessions of ESWT, pain scores significantly decreased (p = 0.04), with continued reduction through six sessions (p < 0.001) and at 1-month follow-up (p < 0.001). Pruritus scores also improved from session two (p = 0.03) and remained significant (p < 0.001, p = 0.001). Between-group differences became apparent after four sessions for pruritus (p = 0.06) and after six sessions for the 5-D Itch scale (p = 0.007). Pregabalin dosage was significantly reduced in the ESWT group (p = 0.04). No adverse effects were reported. CONCLUSION: ESWT, as a noninvasive therapeutic approach, significantly alleviated PHN-associated pain and pruritus.
BACKGROUND: tDCS has demonstrated hypoalgesic effects on Parkinson's disease (PD)-related pain applied in the On state but not in the Off state. We aimed to determine the effect of tDCS in the Off state followed by dopam...BACKGROUND: tDCS has demonstrated hypoalgesic effects on Parkinson's disease (PD)-related pain applied in the On state but not in the Off state. We aimed to determine the effect of tDCS in the Off state followed by dopaminergic medication on PD-related pain. METHODS: This randomized controlled crossover trial included 15 patients (age range 39-81, 5 male) with PD-related pain in the Off state. All participants received both an active and sham tDCS sessions of 20 min over the M1 contralateral to pain at 2 mA intensity in two separate days while in Off state. Following tDCS they took its dopaminergic medication. Outcome measures were assessed at baseline, post-tDCS and post-medication intake. The Numeric Pain Rating Scale (NPRS), Global Rating Of Change (GROC), Conditioned Pain Modulation (CPM), Pain Pressure Thresholds (PPT) and Widespread Mechanical Hyperalgesia (WMH) were evaluated. RESULTS: No significant differences were found after active tDCS in NPRS, GROC, CPM, PPT's or WMH when compared to sham at post-medication intake measure. However, examining exclusive effects of tDCS in the Off state for NPRS, active tDCS was superior to sham tDCS (p = 0.037). No meaningful changes between stimulation conditions were found in GROC, CPM, PPT's and WMH at post-tDCS measure. CONCLUSIONS: One session of tDCS over the M1 alleviates pain perception in PD patients in the Off state. However, tDCS followed by dopaminergic medication intake does not yield additional benefits in pain processing suggesting pathways different to dopaminergic ones in pain regulation in PD patients. These findings are exploratory and carry high risk of type-II error. TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT06214377.
BACKGROUND: Smoking is known to increase the risk of numerous postoperative complications, including increased rates of infection, cardiovascular events, and pulmonary complications. In addition, there may be an effect o...BACKGROUND: Smoking is known to increase the risk of numerous postoperative complications, including increased rates of infection, cardiovascular events, and pulmonary complications. In addition, there may be an effect of smoking on pain in the perioperative period. Through this meta-analysis, we sought to investigate what is known about the relationship between smoking and acute postoperative pain. METHODS: Articles published between January 2003 and December 2023 that compared smokers to nonsmokers and utilized pain scores and/or measured postoperative opioid consumption were selected for review. 95% confidence intervals were utilized to determine statistical significance in standardized mean differences for each outcome between smokers and nonsmokers. RESULTS: The meta-analysis included five studies that assessed postoperative pain scores and opioid requirements in smokers and nonsmokers. In the analysis of pain scores, smokers consistently had higher pain scores overall on all postoperative days (POD) 0 (0.46 [95% CI: 0.26-0.66]), POD1 (0.32 [0.17-0.46]), and POD2 (0.38 [0.24-0.52]). Smokers also demonstrated higher opioid requirements compared to nonsmokers on POD0 (0.62 [0.43-0.80]), POD1 (0.49 [0.36-0.62]), and POD2 (0.70 [0.56-0.84]). Four additional studies were included in our systematic review, which further revealed an association between smoking history and postoperative pain. CONCLUSIONS: Smokers demonstrate increased postoperative pain, as assessed by pain scores and opioid requirements. The ability to anticipate increased postoperative pain in this population has the potential to improve postoperative outcomes for patients with a smoking history.
BACKGROUND: Low back pain is treated using a multidisciplinary strategy that includes several nonsurgical interventions and analgesic medications. However, trends in nonsurgical interventions and analgesic medications us...BACKGROUND: Low back pain is treated using a multidisciplinary strategy that includes several nonsurgical interventions and analgesic medications. However, trends in nonsurgical interventions and analgesic medications used in patients with low back pain remain unclear. This study aimed to investigate trends in nonsurgical interventions and analgesic medications among patients receiving nonsurgical interventions. METHODS: We conducted a retrospective cohort study using the DeSC database (DeSC Healthcare Inc.), which contains health insurance claims and health checkup data of approximately 11 million patients in August 2021. We calculated the age- and sex-adjusted rates of nonsurgical interventions and the proportions of analgesic medications used in patients who underwent nonsurgical interventions for chronic low back pain from 2015 to 2020. All trends were analyzed using the Cochran-Armitage and Jonckheere-Terpstra trend tests. RESULTS: The rate of nonsurgical interventions tended to increase from 1.79 to 4.21 per 100 person-years between 2015 and 2018 and declined slightly to 3.83 per 100 person-years in 2020. Nonsurgical interventions, including spinal cord stimulation, demonstrated a significant increase (p = 0.01), whereas procedures such as epidurals did not show a statistically significant increase (p = 0.19). The age-adjusted rate in females was higher than that in males after 2016. The sex-adjusted rate in patients aged ≥ 60 years showed an increasing trend. Nonsteroidal anti-inflammatory drugs were mostly used among patients receiving nonsurgical interventions; however, the proportion decreased significantly during the study period (p < 0.001). The proportion of patients using opioids was about 23%-30% and also decreased significantly (p < 0.001). The proportions of patients using acetaminophen, antiseizure medications, serotonin noradrenaline reuptake inhibitors, and tricyclic antidepressants increased significantly. CONCLUSION: The present study demonstrated an increasing trend in nonsurgical interventions, with a peak observed in 2018. Among them, interventions including spinal cord stimulation showed a significant upward trend, whereas interventions such as epidurals did not exhibit a statistically significant increase. There was a declining trend in the use of nonsteroidal anti-inflammatory drugs and opioids among these patients. These findings may inform the selection of therapeutic interventions for managing low back pain.
OBJECTIVE: To assess the relationship between needle tip position and contrast spread pattern as well as the presence of vascular spread during cervical transforaminal epidural steroid injection (CTFESI). Additionally, t...OBJECTIVE: To assess the relationship between needle tip position and contrast spread pattern as well as the presence of vascular spread during cervical transforaminal epidural steroid injection (CTFESI). Additionally, to assess how different needle tip positions influence pain reduction effects. METHODS: A total of 185 consecutive patients who received CTFESIs to treat neck and upper extremity pain due to cervical disc herniation or stenosis were included in the study. Data were collected from 287 CTFESIs, including demographic data, numeric rating scale (NRS), and fluoroscopic findings at injection. Needle tip position was categorized into the lateral, middle, and medial third areas of the articular pillar. The contrast spread pattern was classified into epidural, intraforaminal, and extraforaminal. Vascular contrast spread was divided into present and absent. The relationship between needle tip position and contrast spread pattern, as well as the presence of vascular spread, was assessed. The subsequent reductive change in NRS according to needle tip position, contrast spread pattern, and vascular spread was also investigated. RESULTS: Positioning the Needle in the Medial Third of the Articular Pillar Markedly Produced the Proper Epidural Spread of the Contrast as Well as the Absence of the Vascular Spread Compared to the Lateral Third Position. Moreover, a Significant Improvement in Pain Reduction and the Subsequent Epidural Contrast Flow Was Observed and Reproduced Following Needle Placement in the Medial Third Area Compared to the Other Locations. CONCLUSION: Positioning the needle at the medial one-third of the articular pillar during CTFESI promoted improved access to the optimal target area with more spread into the epidural space, as well as providing improved pain reduction.